Event Notification Report for September 17, 1999

THREE I-125 BRACHYTHERAPY SOURCES LOST

Agreement State Event Report #WA-99-027

The following text is a portion of E-mail received from the Washington Department of Health, Division of Radiation Protection:

"THE LICENSEE REPORTED THE LOSS OF THREE I-125 BRACHY SOURCES, AMERSHAM MODEL 6720, 0.529 MICROCURIE EACH [1.587 MICROCURIES TOTAL]. THE SOURCES COME FROM THE MANUFACTURER IN A SET OF TEN SEEDS (SOURCES) IN A DICYL SUTURE. FOR THE APPROPRIATE NUMBER OF SEEDS TO MEET THE INDIVIDUALIZED TREATMENT PLAN IT IS COMMON FOR THE SUTURE TO BE TRIMMED. IN THIS CASE THREE SEEDS WERE TRIMMED BUT WERE UNACCOUNTED FOR DURING A SOURCE COUNT PERFORMED ON THE 17 SEPT. 1999. UPON DISCOVERY OF THE MISSING SOURCES THE LICENSEE HAS PERFORMED SURVEY OF ALL POSSIBLE AREAS WITHIN THE HOSPITAL BUT DID NOT FIND THEM. THEY REPORT THAT THE SOURCES WERE PROBABLY LOST, MIXED WITH SOME OF THE OPERATING ROOM MATERIALS, WHICH HAD BEEN AUTOCLAVED AND DISPOSED OF IN A DUMPSTER WHICH HAD BEEN PICKED UP BEFORE THEY WERE AWARE OF THE MISSING SOURCES. AN INVESTIGATION IS ONGOING MORE DETAILS WILL BE FORTHCOMING."

LOSS OF DIRECT COMMUNICATIONS TO BOTH VERMONT AND MASSACHUSETTS STATE POLICE

The licensee discovered at 0605 EDT that the Nuclear Alert System was not available. Repairs are in progress.

*** UPDATE ON 09/17/99 AT 1111 EDT FROM MALENO TAKEN BY MacKINNON ***

At 1000 hours, power was restored to the Nuclear Alert System.

The R1DO (Niel Della Greca) was notified by the NRC operations officer.

OFFSITE NOTIFICATION MADE TO THE NEW YORK STATE DEPARTMENT OF CONSERVATION OF A SPILL OF LESS THAN ONE GALLON OF LUBE OIL THAT WAS RELEASED INTO THE PLANT'S FLOOR DRAIN SYSTEM WHICH DISCHARGES INTO THE PLANT'S COOLING WATER DISCHARGE CANAL

An oil sheen from less than a one-gallon spill of the lube oil was observed on the surface of the discharge canal. The water of the discharge canal is river water that has been used to cool plant equipment during plant operations. The discharge canal has oil containment barriers that are designed to contain a majority of the oil discharge. Cleanup of the oil spill is in progress.

The NRC resident inspector will be notified of this event by the licensee.

EMERGENCY NOTIFICATION SYSTEM AND LOCAL PHONE COMMUNICATION INOPERABLE

The licensee reported that all FTS-200 and commercial telephone lines went dead. Communication to the plant still is available via cellular telephone or the load dispatcher. The licensee is investigating why the telephone system is inoperable. The onsite telephone representative is working on the problem.

The NRC resident inspector has been notified of this event by the licensee.

********** UPDATE AT 1527 ON 09/17/99 FROM ROGER CHILDERS TO LEIGH TROCINE **********

The cause of the problems was determined to be a line that was cut during the performance of digging at a golf coarse. The line was repaired at approximately 1330 CDT, and subsequent tests revealed that the commercial telephone lines and the Emergency Notification System and Health Physics Network lines are back in service. Based upon these tests, it was assumed that the remaining FTS-2000 lines are also back in service.

The licensee notified the NRC resident inspector and plans to make a courtesy notification to the state. The NRC operations officer notified the R3DO (Shear) and NRR EO (Matthews).

GREATER THAN 10% OF THE EMERGENCY SIRENS ARE INOPERABLE DUE TO TROPICAL STORM FLOYD. (See similar Indian Point Unit 3 event: #36189.)

The licensee was notified at 1050 EDT that 14 out of 77 emergency sirens in Westchester County were inoperable, 10 out of 10 emergency sirens in Putnam county are inoperable, 14 out of 16 emergency sirens in Orange county are inoperable, and it is expected that a significant number of emergency sirens in Rockland county are inoperable. Counties have initiated route alerting procedures. The licensee is currently in the process of trying to restore the inoperable sirens.

The NRC resident inspector will be informed of this event by the licensee.

* * * UPDATE AT 1558 EDT ON 9/23/99 BY JOHN LAMB TO FANGIE JONES * * *

"This notification is a status update to the notification provided on September 17, 1999, (Log No. 36188) which reported that a recent storm (Hurricane Floyd) caused a loss of electric and telephone lines that resulted in greater than 10% of the emergency sirens (60 of 154) not being operational. The emergency siren notification system remains degraded in one of the four counties covered by the emergency plan. Orange County continues to have greater than 10% of its emergency sirens not operational due to power outages. Three (3) in Harriman State Park of sixteen (16) emergency sirens total in Orange County are inoperable. There are two (2) inoperable sirens in Rockland County and two (2) inoperable sirens in Westchester County. All sirens in Putnam County are operational. The emergency plan will continue to use route alerting and public radio announcements to notify the public in lieu of the non-operational sirens. Restoration of the sirens will be coordinated with the restoration plans of the electric and telephone companies."

The licensee notified the NRC Resident Inspector. The R1DO (Robert Summers) was notified.

GREATER THAN 10% OF THEIR EMERGENCY SIRENS HAVE BECOME INOPERABLE DUE TO TROPICAL STORM FLOYD. (See similar Indian Point Unit 2 event: # 36188.)

At 1050 EDT, it was determined that the emergency siren notification system was degraded in each of the four counties (Orange County, Putnam County, Rockland County, and Westchester County). A recent storm caused electric power line outages and telephone line outages in all four counties. The loss of electric and telephone lines resulted in greater than 10% of the sirens not being operational in each county. It is estimated that approximately 60 of the 154 sirens are not operational. The emergency plan would utilize route alerting and public radio announcements to notify the public in lieu of the non-operating sirens. Restoration of the sirens will be coordinated with the restoration plans of the electric companies and telephone companies.

The NRC resident inspector will be notified of this event by the licensee.

* * * UPDATE AT 1609 EDT ON 9/23/99 BY BRIAN ROKES TO FANGIE JONES * * *

"This notification is a status update to the notification provided on September 17, 1999, (Log No. 36189) which reported that a recent storm (Hurricane Floyd) caused a loss of electric and telephone lines that resulted in greater than 10% of the emergency sirens (60 of 154) not being operational. The emergency siren notification system remains degraded in one of the four counties covered by the emergency plan. Orange County continues to have greater than 10% of its emergency sirens not operational due to power outages. Three (3) in Harriman State Park of sixteen (16) emergency sirens total in Orange County are inoperable. There are two (2) inoperable sirens in Rockland County and two (2) inoperable sirens in Westchester County. All sirens in Putnam County are operational. The emergency plan will continue to use route alerting and public radio announcements to notify the public in lieu of the non-operational sirens. Restoration of the sirens will be coordinated with the restoration plans of the electric and telephone companies."

The licensee notified the NRC Resident Inspector. The R1DO (Robert Summers) was notified.

INOPERABLE EMERGENCY NOTIFICATION SYSTEM LINE AND PUBLIC NOTIFICATION SYSTEM DUE TO A DOWNED TELEPHONE LINE

At 1148, a local subcontractor notified the licensee that the Public Notification System (a weather radio system) was inoperable. Apparently, a line is down between the National Weather Service and the licensee's local office. Therefore, no signal is being received from the National Weather Service. Therefore, state of Vermont will be able to call the National Weather Service, but the National Weather Service will be unable broadcast for public notification because this telephone line is down. The licensee stated that repairs are ongoing and that the line may be returned to service at approximately 1500.

A subsequent test of the licensee's Emergency Notification System line revealed that it was also inoperable.

The licensee plans to notify the NRC resident inspector; the applicable local agencies; and the states of Massachusetts, Vermont, and New Hampshire.

*** UPDATE ON 09/18/99 @ 0400 FROM BROOKS TO GOULD ***

THE PUBLIC NOTIFICATION SYSTEM WAS RETURNED TO SERVICE AT 0355 ON 09/18/99. THE EMERGENCY NOTIFICATION SYSTEM WAS VERIFIED OPERABLE AT 0405 ON 09/18/99.

THE RESIDENT INSPECTOR WILL BE NOTIFIED BY THE LICENSEE. THE R1DO (DELLA GRECA) WAS NOTIFIED BY THE NRC OPERATIONS OFFICER.

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO A DROPPED CONTROL ELEMENT ASSEMBLY

At 1346 EDT, a control rod assembly (CEA) dropped into the core and was subsequently declared inoperable. As a result, the licensee plans to commence a unit shutdown at 1425 EDT in accordance with Technical Specification 3.0.3. The licensee plans to place the unit in Mode 3 (Hot Standby) in order to repair the CEA.

The cause of the dropped CEA is under investigation. There were no CEA-related maintenance or surveillance activities ongoing at the time of the event. The unit was at reduced power (65%) to facilitate manual waterbox cleaning due to condenser fouling from Hurricane Floyd. The licensee stated that all systems functioned as required and that there was nothing that was unusual or not understood (other than the cause of the dropped CEA).

The licensee notified the NRC resident inspector.

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO INOPERABILITY OF BOTH STANDBY GAS TREATMENT TRAINS (Refer to event #36195 for additional information.)

The following text is a portion of a facsimile received from the licensee:

"At 1350 [CDT], it was discovered that both Z-sump pumps were inoperable, which causes both standby gas treatment [(SGT)] trains to be inoperable. [Technical Specification Limiting Condition for Operation (TS LCO)] 3.6.4.3, Condition D, Two SGT Subsystems Inoperable in Modes 1, 2, or 3, required action is to enter [TS] LCO 3.0.3 immediately. [TS] LCO 3.0.3 was entered at 1350 [CDT]."

"Surveillance testing of the Z-sump pumps was in progress due to anomalous behavior of the pumps and associated circuitry earlier in the day while placing the augmented offgas system in service."

The licensee plans to place the unit in Mode 4 (Cold Shutdown). The current estimated restart date is 09/20/99.

The licensee notified the NRC resident inspector.

POTENTIAL INOPERABILITY OF THE AUTOMATIC START FUNCTION OF AN AUXILIARY BOILER FEEDWATER PUMP

The following text is a portion of a facsimile received from the licensee:

"With the unit in Hot Shutdown during a review of the Accident Mitigation System Actuation Circuitry (AMSAC), the licensee determined that a condition existed that could have rendered the automatic start of the 21 auxiliary boiler feedwater pump (21 ABFP) inoperable contrary to the requirements of the Safety Evaluation, 'Indian Point Unit 2 ATWS Rule (10 CFR 50.62) (TAC NO. 59103),' issued May 16, 1989. [The] 21 ABFP would have failed to start if the following conditions had existed: 480-volt bus 3A loss of power, no black out condition or safety injection, and an AMSAC condition existed. Consequently, the requirements specified in the SER, 'Equipment, diverse from the [reactor trip system], is required to initiate the auxiliary feedwater (AFW) system and turbine trip for ATWS events,' would not have been met. Since this condition was discovered [while the unit was] in Hot Shutdown, it is reportable under 10 CFR 50.72(b)(2)(i)."

The licensee plans to notify the NRC resident inspector.

AUTOMATIC REACTOR SCRAM FROM 30% POWER DUE TO A MAIN TURBINE TRIP ON MOISTURE SEPARATOR HIGH LEVEL

The following text is a portion of a facsimile received from the licensee:

"At approximately 1702 [CDT] on 09/17/99 during power ascension activities, Unit 2 automatically scrammed on a main turbine trip. Initial indications are that the turbine trip was initiated as a result of moisture separator high level. An investigation is ongoing into the cause of the moisture separator high level. The scram resulted in a low reactor water level causing an automatic isolation of primary containment isolation system (PCIS) groups 2, 3, 6, and 8 [as expected]. EOI-1 was entered due to low reactor water level. Water level was restored to normal with the reactor feedwater system, and EOI-1 was subsequently exited. No main steam safety relief valves (MSRV) were actuated during this event."

"This event is reportable per 10 CFR 50.72(b)(2)(ii) as, 'any event that results in a manual or automatic actuation of any engineered safety feature (ESF).' This event also requires a 30-day written report per 10 CFR 50.73(a)(2)(iv)."

The licensee stated that all control rods fully inserted following the automatic reactor scram and that all actuations that did occur were as expected. All systems functioned as required, and there was nothing unusual or not understood. The low water level signal was received when reactor vessel water level decreased to +11". Reactor vessel water level did not go below 0", and the reactor core isolation cooling and high pressure coolant injection systems actuate at -45". There were no emergency core cooling system actuations, and none were required.

The recirculation pumps automatically tripped due to the turbine trip with the reactor at approximately 30%
power. The licensee was unable to place a recirculation pump back in service prior to exceeding the temperature limitations between the steam dome and bottom head. As a result, the licensee commenced a unit cooldown in order to get back within the required limitation of 145°F. The most recent temperature difference was approximately 200°F.

The unit is currently stable in Mode 3 (Hot Shutdown). The control rod drive system is being used to maintain reactor vessel water level. The condensate and feedwater systems are also available. The main steam isolation valves are open, and the main condenser is being used for cooldown. Containment parameters are normal. The containment isolations have since been reset, and the systems have been returned to normal status as appropriate. Offsite power is available, and the emergency diesel generators are operable and available if needed.

Prior to this event, power ascension activities were in progress on Unit 2 following a shutdown from the previous day due to problems with the electrohydraulic control system. Unit 1 is currently defueled, and Unit 3 is currently operating at 100% power. Units 1 and 3 were not affected by this event.

The licensee notified the NRC resident inspector.

DECLARATION OF AN UNUSUAL EVENT DUE TO A HYDROGEN EXPLOSION WITHIN THE OFFGAS SYSTEM (Refer to event #36192 for additional information.)

Earlier today (09/17/99), a loss of the Zulu sump pumps caused both standby gas treatment trains to be inoperable. This in turn resulted in a technical specification required plant shutdown from 100% power due to loss of the standby gas treatment system. (Refer to event #36192 for additional information.) Subsequent inspections and evaluations determined that the plant sustained a hydrogen explosion within the offgas system some time between 0500 CDT and 0700 CDT on 09/17/99. The hydrogen explosion was contained within the system, but the Zulu sump sustained damage at the base of the elevated release point tower. Indications are that the explosion took place mainly in the sump itself, but there may have been a pressure wave that propagated back through the offgas system. The extent of the damage is under investigation. This sump is part of the offgas system and secondary containment.

The licensee performed a rapid shutdown and manually scrammed the unit from 25% power at 2040 CDT. The rapid shutdown does not allow the unit to flood up to avoid receipt of a low reactor water level. All rods fully inserted. Low water level was received, and this resulted in actuations of primary containment isolation system groups 2 (emergency core cooling systems and various systems within the reactor building containment), 3 (reactor water cleanup), and 6 (heating and ventilation, primary containment purge and vents, standby gas initiation, etc.). The lowest water level was 0" (narrow range). There were no emergency core cooling system actuations, and none were required. The reactor core isolation cooling and high pressure coolant injection systems are required to actuate at -37". The licensee entered emergency operating procedure charts EOI-1A and EOI-5A for low reactor water level and tripping of the reactor building heating and ventilation (due to a secondary containment pressure spike), respectively. The reactor building (secondary containment) differential pressure went positive and then immediately went negative. This was recovered using the standby gas system.

The unit is currently stable in Hot Shutdown, and the licensee plans to place the unit in Cold Shutdown. Normal feedwater and the control rod drive system are being used to supply water to the reactor vessel. The main steam isolation valves are open, and the main condenser is available as a heat sink. Reactor pressure is currently stable, and the bypass valves are closed at this time. Containment parameters are normal.

As a result of the explosion within the protected area, the licensee declared an Unusual Event at 2056 CDT on 09/17/99. The Unusual Event termination criteria is to ensure that there is no more hydrogen left in the system via the shutdown of the augmented offgas system and the completion of the required air purge until the length of time (required by procedures) has been doubled. The licensee stated that there is no possibility that another explosion would occur at this time because the system has been purged. The initial problem was the result of a procedural problem that caused a valve to be throttled which backed up hydrogen in the system. That has since been suspended, and the augmented offgas system has been taken off line.

The current wind speed of 14.3 mph is coming from 135°. There is no precipitation in the area, and the plume stability class is F. There has been no release of radioactive materials greater than technical specification limits, and there are no protective action recommendations. The licensee stated that the situation is stable.

The licensee notified the NRC resident inspector and the state. (Call the NRC operations officer for a site contact telephone number.)

*** UPDATE ON 09/18/99 @ 0224 EDT FROM SCHIZAS TO GOULD ***

THE PLANT TERMINATED THE UNUSUAL EVENT AT 0107 CDT ON 09/18/99 DUE TO COMPLETION OF ALL VENTING ACTIVITIES IN THE OFFGAS SYSTEM. THERE IS NO POSSIBILITY OF FURTHER EXPLOSIONS DUE TO HYDROGEN GAS CURRENTLY EXISTING. THE PLANT IS STABLE AND COOLING DOWN TO MODE 4.

THE NRC RESIDENT INSPECTOR WILL BE INFORMED BY THE LICENSEE. THE R4DO (PELLET), IRO (CONGEL), NRR EO (MATTHEWS), AND FEMA (BELCHER) WERE NOTIFIED BY THE NRC OPERATIONS OFFICER.